Date: ______________________
RE: Case of: ________________
Expiration date: ______________
I, ______________, give permission for Carl Grody, LISW-S, to discuss details of the case involving _________________________ with ____________________________________. The purpose of such communication is for continuity of care. I also give permission for ________________ to discuss details of the case with Mr. Grody.
I agree that Mr. Grody may communicate through in-person conversations, phone calls, e-mails, and/or letters with _______________. This release does not cover any exchange of records involving _________________’s case.

Printed name of parent/legal guardian: _______________________
Signature of parent/legal guardian: __________________________
Date of signature: ________________________________________
Witness signature: _______________________________________
Date of witness’ signature: _________________________________